Cincinnati Podiatrist | Center for Foot Care | Dr. Kristin ...



Dr. Kristin K. Titko

513-729-4455

CHECKLIST: Review of Systems

|General- | Cardiovascular- |Endocrine- |

|Weight loss |Cold feet | |

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| Weight gain |Night cramps |Sweating |

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|Fatigue |Intermittent claudication |Frequent urination |

|Fever or chills |Swelling of feet/ankles |Thirst |

|Weakness |Heart disease |Change in appetite |

|Loss of Appetite | |Diabetes |

| |Gastrointestinal- |If yes - Type 1 or Type 2 |

|Skin- |Indigestion (Dyspepsia) | |

| |Ulcers | |

|Itching (pruritis) |Diarrhea | Surgical Concerns- |

|Dryness |GI bleeding |Anesthesia problems |

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|Open wounds |Liver disease |Wound healing |

|Nail changes/fungus | | problems |

|Rashes | Vascular- | |

| |Calf Pain with walking | Please check if you are |

|Respiratory- |Leg cramping | being treated for any |

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|Shortness of breath | | of the following: |

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|COPD | Psychiatric- |Thyroid |

|Painful breathing |Nervousness |Osteopenia |

|Asthma |Stress |Drug abuse |

|Cough |Depression |COPD |

| |Memory loss |AIDS/HIV |

|Musculoskeletal-Joint/muscle stiffness | |Hepatitis |

|Joint/muscle stiffness | Neurologic- |Alcoholism |

|Back pain |burning in feet/legs |Alzheimer’s |

|Redness of joints |Seizures |Blood Clots where? |

|Swelling of joints |Unsteady gait |Cancer where? |

|Osteoarthritis |Tremors |High Cholesterol |

|Gout |Dizziness |Diabetes |

|Rheumatoid Arthritis |Fainting | High Blood Pressure |

|Muscle or joint pain |Tingling in feet/legs | CVA/Stroke |

| |Numbness in feet/legs feet/ankles | ⎕ Kidney Disease |

|Hematologic- |Weakness in feet/legs | ⎕Take Blood Thinner |

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|Ease of bleeding | | Current weight?__________ |

|List Other Medical Conditions: | | |

| | |Current height?___________ |

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|Ease of bruising | | |

I do not have any of the above conditions

Patient’s Name: ____________________________

Patient Signature:___________________________ Date: ____________________

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